Personal Hygiene and Bed Making Guide
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This document discusses personal hygiene and bed making. It covers topics like hygiene, principles for practice, patient-centered care, evidence-based practice, safety guidelines, the skin, mouth, hair, nails, bed baths, oral hygiene, hair care, and nail/foot care. Key points include the importance of regular hygiene for health, accommodating patient preferences, using techniques to prevent injury, and considering special needs of populations like pediatrics, geriatrics, and home care patients.
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Personal Hygiene and Bed Making Guide
- 1. Chapter 18 Personal Hygiene and Bed Making Copyright © 2018, Elsevier Inc. All rights reserved.
- 2. Hygiene Promotes and preserves health When performing hygiene, the nurse can: Discuss health-related concerns Perform a physical assessment Provide patient education Providing personal hygiene is necessary for an individual’s comfort, safety, and sense of well-being Copyright © 2018, Elsevier Inc. All rights reserved. 2
- 3. Principles for Practice Regular bathing is essential to skin integrity Promotes circulation and hydration Bathing patients with dementia is complicated Difficult to apply physical, emotional, and environmental factors Maintain privacy and comfort Encourage patients to participate in hygiene care Copyright © 2018, Elsevier Inc. All rights reserved. 3
- 4. Patient-Centered Care Accommodate patient’s preferences and culture when performing hygiene Consider patient’s normal oral and bathing hygiene routines Involve family members when possible Preserve patient dignity of patients with dementia Copyright © 2018, Elsevier Inc. All rights reserved. 4
- 5. Evidence-Based Practice Recent evidence supports the use of daily bathing with chlorhexidine gluconate A recent systematic review and meta-analysis confirmed that 2% CHG reduces central line associated bloodstream infections (CLABSIs) Copyright © 2018, Elsevier Inc. All rights reserved. 5
- 6. Safety Guidelines 1. Patients who are totally dependent on someone else require assistance with personal hygiene or must learn or adapt new hygiene techniques. 2. Keep all personal hygiene care items within a patient’s reach. 3. Use clean gloves when you anticipate contact with nonintact skin or mucous membranes or when there is or may likely be contact with drainage, secretions, excretions, or blood. Copyright © 2018, Elsevier Inc. All rights reserved. 6
- 7. Safety Guidelines (Cont.) 4. Always perform hygiene measures moving from cleanest to less clean or dirty areas. 5. When using water or solutions for hygiene care, be sure to test the solution temperature to prevent burn injury. 6. Use principles of body mechanics and safe patient handling. 7. Assess and evaluate a patient before and after care. 8. Monitor laboratory findings. Copyright © 2018, Elsevier Inc. All rights reserved. 7
- 8. The Skin The largest human body organ Three primary layers Epidermis Dermis Subcutaneous tissue What common skin problems might you observe? Copyright © 2018, Elsevier Inc. All rights reserved. 8
- 9. The Mouth The oral cavity Teeth Gums Saliva Regular oral hygiene is necessary for health 9Copyright © 2018, Elsevier Inc. All rights reserved.
- 10. The Hair Grows from follicles Supporting structures Blood vessels Sebaceous glands Purpose is protection Condition indicates health 10Copyright © 2018, Elsevier Inc. All rights reserved.
- 11. The Nails • Epithelial tissues • Grow from the root of the nail bed • Indicate health • Feet and nails require special care to prevent infection, odor, and injury Copyright © 2018, Elsevier Inc. All rights reserved. 11
- 12. Quick Quiz! A male nurse is preparing to help shampoo the hair of an Amish woman. The woman refuses the nurse’s assistance. What action should the nurse take? A.Explain to the woman that this is the only time the nurse has to help her. B.Seek the assistance of a female nurse to put the patient more at ease. C.Enlist the help of family members, giving them the supplies needed to complete the care. D.Leave the patient alone; eventually she will need to cooperate with the male nurse. Copyright © 2018, Elsevier Inc. All rights reserved. 12
- 13. Complete or Partial Bed Bath Skill 18-1 Bathing principles Clean skin regularly and at time of soiling Avoid extreme water temperatures Avoid use of force or friction Maintain an ideal room temperature Assess patient during the bath Assist with range-of-motion (ROM) exercises during the bath Keep patient limitations in mind Copyright © 2018, Elsevier Inc. All rights reserved. 13
- 14. Complete or Partial Bed Bath Skill 18-1 (Cont.) Cleansing bath Bed Tub Sponge Shower Therapeutic bath Sitz Medicated Copyright © 2018, Elsevier Inc. All rights reserved. 14
- 15. Delegation and Collaboration The task of bathing can be delegated to nursing assistive personnel (NAP) The nurse instructs NAP about: Not massaging reddened skin areas Contraindications to soaking patient’s feet Reporting impaired skin integrity Proper patient positioning Copyright © 2018, Elsevier Inc. All rights reserved. 15
- 16. Recording and Reporting • Record procedure, observations, level of patient participation, and how the patient tolerated procedure in nurses’ notes in electronic health record (EHR) or chart • Report evidence of alterations in skin integrity, break in suture line, or increased wound secretions to nurse in charge or health care provider. Patient may require special skin care Copyright © 2018, Elsevier Inc. All rights reserved. 16
- 17. Special Considerations Teaching Teach patients how to inspect surfaces between skinfolds and explain the signs of irritation or breakdown Include family caregiver in learning the bathing process Pediatric Adolescents may require more frequent bathing because they have active sebaceous glands Young adolescent girls should learn basic perineal hygiene measures Copyright © 2018, Elsevier Inc. All rights reserved. 17
- 18. Special Considerations (Cont.) Gerontological Incontinence requires meticulous skin care Caregiver behavior can be considered by the patient as assault in dementia patients Guidelines for dementia patients: Do not rush Speak in low, pleasant voice Inform patient all through bath Use distraction if agitation occurs Concentrate on the person’s feelings and reaction Copyright © 2018, Elsevier Inc. All rights reserved. 18
- 19. Special Considerations (Cont.) Home care Type of bath chosen depends on assessment of the home, availability of running water, and condition of bathing facilities Set up equipment according to patient’s established routines Use assist devices for patients at risk of fall Long-term care Use baths with thermometers and hydraulic patient lifts as needed Copyright © 2018, Elsevier Inc. All rights reserved. 19
- 20. Quick Quiz! The nurse will administer a complete bed bath to which of the following patients? A.12-year-old boy with a long leg cast B.92-year-old woman in assisted living C.25-year-old ventilator-dependent man D.40-year-old patient with Parkinson’s disease Copyright © 2018, Elsevier Inc. All rights reserved. 20
- 21. Perineal Care Procedural Guideline 18-1 Performed during a complete bed bath May be performed more frequently on patients with fecal or urinary incontinence, an indwelling Foley catheter, or rectal or genital surgery Wear gloves Always act in a professional manner and provide privacy at all times Copyright © 2018, Elsevier Inc. All rights reserved. 21
- 22. Delegation and Collaboration The task of perineal care can be delegated to NAP The nurse instructs NAP to: Avoid any physical restriction that affects proper positioning of patient Properly position a patient with an indwelling Foley catheter Inform the nurse of any perineal drainage, excoriation, or rash observed Copyright © 2018, Elsevier Inc. All rights reserved. 22
- 23. Use of Disposable Bed Bath, Tub, or Shower Procedural Guideline 18-2 Disposable washcloths (CHG) have antiseptic solution Replace soap and water baths Cleanse and remove bacteria Antiseptic binds to skin for persistent antibacterial activity Tub and shower bathing is more common in long-term care Copyright © 2018, Elsevier Inc. All rights reserved. 23
- 24. Delegation and Collaboration The task of bathing in a tub or shower or using a disposable bed bath can be delegated to NAP The nurse instructs NAP to: Not massage reddened skin Properly position patient Report changes in skin or perineal area or signs of impaired skin integrity Copyright © 2018, Elsevier Inc. All rights reserved. 24
- 25. Oral Hygiene Skill 18-2 Daily oral hygiene prevents and controls plaque- associated oral disease Oral hygiene promotes health, comfort, nutrition, and verbal communication Ill patients may require assistance with activities ranging from preparing supplies to brushing teeth Care for dentures as frequently as natural teeth Copyright © 2018, Elsevier Inc. All rights reserved. 25
- 26. Delegation and Collaboration The task of oral hygiene can be delegated to NAP The nurse instructs NAP to: Note types of changes in oral mucosa Report patient’s complaints of pain or occurrence of bleeding during oral care Be aware of special precautions, such as aspiration precautions Not floss when a patient has a bleeding tendency Copyright © 2018, Elsevier Inc. All rights reserved. 26
- 27. Recording and Reporting • Record procedure and note condition of oral cavity in nurses’ notes • Report bleeding, pain, or presence of lesions to nurse in charge or health care provider Copyright © 2018, Elsevier Inc. All rights reserved. 27
- 28. Special Considerations Teaching Teach patients about methods to prevent tooth decay Educate patients to visit a dentist regularly Include family caregiver in teaching Avoid mints Pediatric Every infant should have oral assessment Oral hygiene starts no later than first eruption Use smear of toothpaste with first tooth Teach parents that infants should be put to bed with a bottle Copyright © 2018, Elsevier Inc. All rights reserved. 28
- 29. Special Considerations (Cont.) Gerontological Normal age-related changes Home care During initial admission, document condition of patient’s mouth, teeth, and gums to provide a baseline for assessing patient’s ability to comply with special diets and fluid intake and to carry out oral hygiene practices Copyright © 2018, Elsevier Inc. All rights reserved. 29
- 30. Care of Dentures Procedural Guideline 18-3 Clean dentures as often as natural teeth Store in an enclosed, labeled cup when not worn Reinsert as soon as possible When inserting, ensure a good fit Loose dentures cause discomfort and make it difficult to chew food and speak clearly Copyright © 2018, Elsevier Inc. All rights reserved. 30
- 31. Delegation and Collaboration The task of denture care can be delegated to NAP The nurse instructs NAP to: Understand the importance of water temperature when caring for dentures Inform the nurse if there are cracks in dentures Inform the nurse if the patient has any oral discomfort Copyright © 2018, Elsevier Inc. All rights reserved. 31
- 32. Quick Quiz! Which of the following issues can contribute to malnutrition for an elderly man? A.Loose-fitting dentures B.Moist mucous membranes C.Visible layer of tooth enamel D.Clear-colored saliva Copyright © 2018, Elsevier Inc. All rights reserved. 32
- 33. Performing Mouth Care for the Unconscious or Debilitated Patient Skill 18-3 These patients are at risk for: Alterations of the oral cavity Infection Aspiration For safety, two nurses/NAPs provide care One nurse or NAP provides oral care, while the other suctions oral secretions Copyright © 2018, Elsevier Inc. All rights reserved. 33
- 34. Delegation and Collaboration The task of providing oral hygiene to an unconscious or debilitated patient can be delegated to NAP The nurse instructs NAP to: Have another NAP assist Properly position patient for mouth care Use special precautions (e.g., aspiration) Use an oral suction catheter Report impaired integrity of oral mucosa Report bleeding, coughing, or choking Copyright © 2018, Elsevier Inc. All rights reserved. 34
- 35. Recording and Reporting • Record procedure, appearance of oral cavity, presence of gag reflex, and patient’s response to procedure in medical record in EHR or chart • Report any unusual findings (e.g., bleeding, ulceration, choking response) to nurse in charge or health care provider Copyright © 2018, Elsevier Inc. All rights reserved. 35
- 36. Special Considerations Teaching Instruct family members on mouth care, and how to prevent aspiration Use teach-back Home care Irrigate oral cavity with bulb syringe Instruct on risk of aspiration Encourage oral cleansing twice a day Copyright © 2018, Elsevier Inc. All rights reserved. 36
- 37. Hair Care—Combing and Shaving Procedural Guideline 18-4 Brushing, combing, and shampooing are basic measures for all patients unable to provide self-care Many factors can influence the health of the scalp and the condition of the hair Dependent patients with beards or mustaches need assistance keeping facial hair clean; keep cultural considerations in mind and obtain consent as needed Copyright © 2018, Elsevier Inc. All rights reserved. 37
- 38. Delegation and Collaboration The tasks of combing and shaving can be delegated to NAP The nurse instructs NAP to: Properly position the patient with head or neck mobility restrictions Report how the patient tolerated the procedure and any concerns Use an electric razor for any patient who is at risk for bleeding tendencies Copyright © 2018, Elsevier Inc. All rights reserved. 38
- 39. Hair Care—Shampooing Procedural Guideline 18-5 Frequency of shampooing depends on the condition of the hair and the person’s daily routines and cultural preferences Two types of shampooing are available: Traditional soap and water Disposable dry shampoo cap Make sure that a patient’s condition does not contraindicate neck hyperextension Copyright © 2018, Elsevier Inc. All rights reserved. 39
- 40. Delegation and Collaboration The task of shampooing the hair of bed-bound patients and the use of disposable shampoo product can be delegated to NAP The nurse instructs NAP about: Proper way to position a patient with a head or neck mobility restriction How to provide care for patients with lice, stressing steps that should be taken to prevent transmission to other patients Copyright © 2018, Elsevier Inc. All rights reserved. 40
- 41. Performing Nail and Foot Care Skill 18-4 When is the best time to provide nail and foot care? Patients with peripheral neuropathy and peripheral vascular disease (PVD) are at greatest risk for developing serious foot problems PVD is a factor in diabetic foot ulcers Teach patients about proper foot care Copyright © 2018, Elsevier Inc. All rights reserved. 41
- 42. Delegation and Collaboration The task of providing nail and foot care for patients without diabetes or circulatory compromise can be delegated to NAP The nurse instructs NAP about: Not trimming patient’s nails Special considerations for patient positioning Reporting any breaks in skin, redness, numbness, swelling, or pain Copyright © 2018, Elsevier Inc. All rights reserved. 42
- 43. Recording and Reporting • Record procedure and observations of condition of nails and skin around nails in medical record • Report any areas of discomfort, breaks in skin or ulcerations to nurse in charge or health care provider Copyright © 2018, Elsevier Inc. All rights reserved. 43
- 44. Special Considerations Teaching Do not walk barefoot or use corn or callus products The patient with diabetes Pediatric Trim children’s nails to prevent injury from scratching themselves Use clippers, not scissors Copyright © 2018, Elsevier Inc. All rights reserved. 44
- 45. Special Considerations (Cont.) Gerontological Age-related skin changes Impaired mobility Home care Assess home for foot injury risks Avoid going barefoot/wearing open-toed shoes Consider alternative therapy Post provider contact information Copyright © 2018, Elsevier Inc. All rights reserved. 45
- 46. Making an Occupied Bed Procedural Guideline 18-6 This skill is easiest with two people Position the patient safely while the bed linens are changed Try to conserve the patient’s energy Use safe handling techniques Copyright © 2018, Elsevier Inc. All rights reserved. 46
- 47. Delegation and Collaboration The task of making an occupied bed can be delegated to NAP The nurse instructs NAP about: Being aware of any position or activity restrictions Looking for wound drainage, drainage tubes, or intravenous (IV) tubing Obtaining help with positioning patient Using special precautions such as aspiration precautions Copyright © 2018, Elsevier Inc. All rights reserved. 47
- 48. Making an Unoccupied Bed Procedural Guideline 18-7 Types of bedmaking Unoccupied bed Postoperative surgical bed Closed bed Copyright © 2018, Elsevier Inc. All rights reserved. 48
- 49. Delegation and Collaboration The task of making an unoccupied bed can be delegated to NAP The nurse instructs NAP about: Position or activity restrictions that apply to patient’s ability to get out of bed Use of special linen instructions if patient is on an airflow mattress Copyright © 2018, Elsevier Inc. All rights reserved. 49
Editor's Notes
- This chapter reviews four skills and seven procedures: complete or partial bed bath, perineal care, use of disposable bed bath, tub, or shower, oral hygiene, care of dentures, performing mouth care for the unconscious or debilitated patient, hair-care combing and shaving, hair-care shampooing, performing nail and foot care, making an occupied bed, and making an unoccupied bed.
- Bathing people with dementia is a complicated process of applying physical, emotional, and environmental factors to the care recipient's best advantage in order to promote a safe, acceptable, and comfortable bathing process for cleansing the person's skin.
- Always convey sensitivity and respect for a patient’s personal cultural beliefs and habits in the way you provide hygiene. Skin problems cause changes that affect a patient’s appearance and body image. Be sensitive to a patient’s feelings while caring for skin problems. It is important to understand if a patient’s ethnicity requires certain customs to be followed in the way personal hygiene is performed. Be sure to take each patient’s preferences into consideration when providing hygiene. Simply asking patients about their preferences (e.g., products to use, best time to perform aspects of hygiene) can create a more trusting and nurturing environment. Depending on cultural considerations and the ability of a patient to assist with care, it may be beneficial to involve a family member or significant other in the patient’s hygiene so complete culturally sensitive patient-centered care is provided. Preserve the dignity of patients with dementia by shifting the focus of care from tasks of bathing to needs and abilities of the person being bathed with emphasis on comfort, safety, autonomy, and self-esteem. [Ask students: what are some cultural considerations that might apply to personal hygiene? Discuss: for example, in some cultures, it is not appropriate to expose the lower torso and arms, and the left hand is used for cleansing the perineal area. In other cultures, health care providers must be gender congruent whenever possible.]
- Multiple studies conducted in long-term acute care facilities and both medical and surgical intensive care units support that daily bathing with 2% chlorhexidine gluconate (CHG) (cloths or in bath water) substantially reduces colonization and bloodstream health care–associated infections (HAIs), including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) infections. CHG-impregnated bathing cloths are more expensive than using CHG solution in bath water, however both methods of bathing are effective. If using CHG solution in bath water, it is important to reserve a bath basin only for bathing and not use the basin for storage. Bathing should be provided daily. Use of chlorhexidine gluconate–impregnated bathing cloths is well tolerated by the skin and is an effective at removing bacteria.
- When providing personal hygiene important safety principles to follow are prevention of infection and prevention of patient injury. When the head of the bed is raised, the bedside stand is usually not within easy reach and must be moved forward. If a patient must leave the bed to go to the bathroom, be sure that there is a clear pathway to prevent falls. Additional precautions requiring other personal protective equipment (PPE) may be necessary, depending on the patient’s condition.
- To reduce the risk of infection, always perform hygiene measures moving from cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities. When using water or solutions for hygiene care, be sure to test the solution temperature to prevent burn injury. This is especially important for patients with reduced sensation, such as those with diabetes, peripheral neuropathy or spinal cord injury. It is also important for patients unable to communicate. To avoid injury when performing hygiene care, use principles of body mechanics and safe patient handling. You are responsible and accountable for assessing and evaluating a patient before and after care to detect unexpected outcomes and give proper direction to NAP when delegating hygiene care. Monitor laboratory findings such as coagulation studies before administering oral care to prevent bleeding.
- Thorough hygiene is essential for the integrity and function of each skin layer. The skin covers the entire surface of the body and is continuous with mucous membranes. [Ask students: what are the many functions of the skin? Discuss: the skin protects the body from heat, light, injury, and infection and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent the entry of bacteria.] The epidermis, or outer skin layer, is the first line of defense against external injury and infection. Two types of sweat glands, eccrine and apocrine glands, are distributed over the surface of the skin. The subcutaneous tissue layer contains blood vessels, nerves, lymph tissue, and loose connective tissue filled with fat cells. Resident skin bacteria are normal flora that do not cause disease but prevent disease-causing microorganisms from reproducing. A portion of the skin is usually exposed to environmental irritants, and some skin problems commonly occur as a result. [Review with students Table 18-1, Common Skin Problems.]
- The membranous lining protects underlying organs; secretes mucus to keep the oral cavity lubricated; and absorbs water, salts, and other solutes. Saliva is a clear viscous fluid secreted by the mucous and salivary glands of the mouth. Saliva helps to prevent dental caries and plaque formation and lubricates the oral cavity. [Ask students: why is it important to lubricate the oral cavity? Discuss: lubrication of the oral cavity aids in chewing and swallowing.] Saliva provides a means for removing cellular and bacterial debris that can cause infection, particularly fungal infection. Hyposalivation results in dry mouth, or xerostomia, and effects taste, swallowing, digestion, nutrition, and denture fit. The teeth are organs of chewing, or mastication. Dentin forms the majority of a tooth. Enamel covers the outer portion of the tooth, or crown. The periodontal membrane surrounds the tooth and holds it firmly in place. A tooth receives its blood, lymph, and nerve supply from the base of the tooth socket within the jaw. Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and prevent gingivitis, or gum inflammation. [Shown is Figure 18-1: Normal tooth.] The gums, or gingivae, are mucous membranes with underlying supportive fibrous tissue. Gums encircle the necks of erupted teeth to hold them firmly in place.
- Hair grows from follicles located within the dermis of the skin. Tiny blood vessels supply each follicle with nourishment necessary for normal hair growth. Each hair has a shaft extending from the follicle. Sebaceous glands secrete the oily substance (i.e., sebum) into each follicle, which lubricates the hair and scalp. [Shown is Figure 18-2: Cross section of hair follicle and supporting structures.] [Ask students: how does hair protect us? Discuss: hair protects the scalp from injury. Eyebrows and eyelashes protect the eyes from foreign particles.] The primary function of hair is to act as the first line of protection. Eyebrows and eyelashes protect the eyes from foreign particles. Hair growth, distribution, and pattern are indicators of a person’s health status. The hair shaft is normally shiny and pliant and is not excessively oily, dry, or brittle. Hormonal changes, emotional and physical stress, aging, intake of toxins (e.g., arsenic, cocaine), gender, race, nutrition, infection, and certain diseases affect hair characteristics.
- The nails are epithelial tissues that grow from the root of the nail bed, located in the skin at the nail groove. A normal, healthy nail is transparent, smooth, and convex, with a pink nail bed and a translucent white tip. A normal color indicates adequate oxygenation to peripheral tissues. Pigment deposits or bands are common in nail beds of patients with dark skin. Problems typically result from abuse or poor care of feet and nails Foot pain can often change a walking gait, causing strain on different muscle groups.
- Correct answer: B Rationale: Amish individuals consider touching unrelated males and females taboo. Use gender-congruent caregivers whenever possible.
- Bathing removes sweat, oil, dirt, and microorganisms from the skin. It also stimulates circulation and provides a refreshed and relaxed feeling. For some patients a bath is a time for socialization and pleasure, especially for those who are bedridden or seriously disabled Avoid massaging reddened areas, especially over bony prominences Minimize environmental factors that lead to skin drying such as low humidity (less than 40%) and exposure to cold [Ask students: what factors influence an ideal room temperature? Discuss: depending on the patient’s age and physical condition, maintain room temperature at between 20°C and 23°C (68°F and 74°F). Infants, older adults, and acutely ill patients may need a warmer temperature. However, certain critically ill patients require cooler room temperatures to lower the metabolic demands of the body. Controlling drafts and eliminating lingering odors from draining wounds, vomitus, bedpans, and urinals also improve a patient’s comfort.] For patients who tire easily, consider giving a partial versus a complete bed bath
- The type of cleansing bath to use depends on assessment of a patient’s physical capabilities and the degree of hygiene required. When a person is unable to perform personal care because of illness or disability, you are responsible for helping with bathing, which includes cleaning and grooming hair, shaving, and cleaning nails. A patient routinely receives perineal care during a bath. Patients at risk for acquiring an infection need more frequent perineal care. A complete bed bath is given only to entirely dependent patients confined to bed. Health care providers generally order therapeutic baths for a specific effect such as soothing the skin or for promoting the healing process. Types of therapeutic baths include: Sitz bath: cleans and reduces pain and inflammation of perineal and anal areas. Used for a patient who has undergone rectal or perineal surgery or childbirth or has local irritation from hemorrhoids or fissures. The patient sits in a special tub or basin (see Chapter 40). Medicated bath (addition of over-the-counter, herbal, or health care provider–ordered ingredient to bath): relieves skin irritation and creates an antibacterial and drying effect. Patients at risk for acquiring an infection need more frequent perineal care such as those who have incontinence-associated dermatitis (IAD), an indwelling Foley catheter, are postpartum, or are recovering from rectal or genital surgery. [Review with students Box 18-1, Types of Baths.]
- Assessment of the patient’s skin, pain level, and range of motion (ROM) cannot be delegated to nursing assistive personnel (NAP) . Proper ways to position male and female patients with musculoskeletal limitations or an indwelling Foley catheter or other equipment (e.g., intravenous [IV] tubing). [Ask students: what are some factors that would influence how male and female patients should be positioned during bathing? Discuss: musculoskeletal limitations or an indwelling Foley catheter or other equipment (e.g., IV tubing).]
- [Ask students: what skin conditions or significant findings should be recorded? Discuss: reddened areas, bruises, nevi, joint or muscle pain.]
- [Ask students: why should you teach patients to inspect skin folds? Discuss: signs of irritation or breakdown.] Teaching Teach patients how to inspect surfaces between skinfolds and explain the signs of irritation or breakdown. Use simple language. Consider the need to include a family caregiver in learning the bathing process. Plan for a return demonstration. Pediatric Some adolescents require and/or prefer more frequent bathing as a result of more active sebaceous glands. Young adolescent girls should learn basic perineal hygiene measures and know why they are predisposed to urinary tract infections.
- Older adults with incontinence need meticulous skin care to reduce incontinence-associated dermatitis and the risk of infection. The use of barrier creams is sometimes recommended to keep the skin intact and free from infections. If patients have signs of dementia, caregiver behavior, especially five seconds prior to a bath may be considered by the patient as an assault. Behaviors that trigger agitation include confrontational communication; invalidation of the patient’s feelings; absence of personal restraint; touching feet, axilla, or perineal area; non–bath-related communications; and failing to prepare the resident for the bath. When giving a patient with dementia a bath, follow these guidelines. Do not rush and speak in a low pleasant voice, giving information before and all through the bathing process. If agitation occurs, use distraction, bring up a pleasant topic or use other distraction such as music, singing, holding an object, or eating. Concentrate on the person's feelings and reactions. Pay attention and don't converse with others.
- Home care Type of bath chosen depends on assessment of the home, availability of running water, and condition of bathing facilities. In the home setting, set up equipment according to established routines. Patient is the best resource for what works in terms of convenience and saving time. [Ask students: what are some examples of fall prevention measures that are useful for bathing? Discuss: installation of grab bars in shower, adhesive strips applied to shower or tub floor, addition of a shower chair or placement of a chair or stool.]
- Correct answer: C Rationale: A complete bed bath is a bath administered to a totally dependent patient in bed. All other patients described here are not confined to bed. No other information is provided on the other patients that would lead the nurse to assume that they cannot participate in their own hygiene care.
- Perineal care involves thorough cleansing of the patient’s external genitalia and surrounding skin. Wear gloves during perineal care because of the risk of contacting infectious organisms present in fecal, urinary, or vaginal secretions. To avoid embarrassment, always act in a professional and sensitive manner and provide privacy at all times.
- [Ask students: what types of physical restrictions would affect proper positioning of the patient?]
- The use of disposable washcloths impregnated with an antiseptic solution like chlorhexidine gluconate (CHG) is more common now in acute care hospitals, especially critical care settings. CHG cloths should be used for all bathing purposes, including once a day full-body bathing, incontinence care, or for any other reasons for additional cleaning. CHG replaces soap and water baths so the cloths should not be used as a "top coat" after bathing. Rather, CHG cloths cleanse and remove bacteria and the antiseptic binds to the skin for persistent antibacterial activity lasting 24 hours. When patients use a tub or shower, follow guidelines to maintain patient safety to prevent falls. [Review safety factors in the environment and factors affecting fall risk status.]
- [Ask students: what considerations might require special positioning during bathing? Discuss: musculoskeletal limitations or an indwelling Foley catheter or other equipment (e.g., intravenous tubing).]
- [Ask students: what are the components of oral hygiene? How are they important? Discuss: brushing, flossing, and rinsing. Brushing cleans the teeth of food particles, plaque (the cause of dental caries), and bacteria; massages the gums; and relieves discomfort from unpleasant odors and tastes. Flossing removes tartar that collects at the gum line. Rinsing removes dislodged food particles and excess toothpaste.] It is your responsibility to determine the frequency at which patients require oral hygiene. Plan the frequency of care based on the condition of the oral cavity and the patient’s level of comfort. In addition to recommendations for the general population, there are oral-care regimens designed to relieve discomfort and facilitate healing of chemotherapy- and radiation therapy–related mucositis, stomatitis, and xerostomia. These type of oral lesions are very painful and interfere with a patient’s nutrition.
- Before the NAP performs oral hygiene, the nurse is responsible for assessing the patient’s gag reflex to determine whether the patient is at risk for aspiration. The nurse instructs the NAP about: Types of changes in oral mucosa (e.g., presence of lesions or open areas) for which to observe and report to the nurse. Reporting patient’s complaints of pain or occurrence of bleeding during oral care. Being aware of special precautions such as aspiration precautions, including: Keeping head of bed (HOB) raised 30 to 45 degrees (not lower). Explaining need to report excessive coughing or choking during procedure. Not flossing when a patient has a bleeding tendency. [Ask students: what are some examples of special precautions? Discuss: keeping head of bed raised to no lower than 30 degrees, and explaining the need to report excessive coughing or choking during procedure.]
- [Discuss examples of descriptors of oral cavity conditions.]
- Teaching Educate patients about methods to prevent tooth decay (e.g., reduce intake of carbohydrates, especially sweet sticky snacks between meals; brush within 30 minutes of eating sweets; rinse mouth thoroughly with water or alcohol-free antiseptic mouth rinse; use fluoride toothpaste). Use simple language and available teaching materials and proper literacy level. Educate patients to visit a dentist regularly (based on dentist’s recommendations) for professional cleaning and oral examination; frequency of visits vary for each patient and should be determined by his or her dentist. When teaching special oral-care regimens, include family caregiver. Avoid mints if there are conditions of the mouth that are associated with ulcerations of the oral mucosa. [Ask students: what are some methods to prevent tooth decay? Discuss: reduce intake of carbohydrates, especially sweet sticky snacks between meals; brush within 30 minutes of eating sweets; rinse mouth thoroughly with water or alcohol-free antiseptic mouth rinse; use fluoride toothpaste; make regular visits to the dentist.] Pediatric Every infant should receive an oral health risk assessment from his or her primary health care provider or qualified health care professional by 6 months of age. Oral hygiene measures should be started no later than the time of eruption of the first primary tooth. Toothbrushing should be performed for children by a parent twice daily, using a soft toothbrush of age-appropriate size and the correct amount of fluoridated toothpaste. As soon as a child has a tooth use a smear (size of a grain of rice) of fluoride toothpaste. Clean the teeth right after breakfast and before bedtime. Once a child turns 3 use a pea-sized amount of fluoride toothpaste. When a child is able, teach him or her to spit out the excess toothpaste, but don't rinse with water. As a child gets older let him or her use own toothbrush. It is best to put the toothpaste on the toothbrush until a child is about age 6. Until children are 7 or 8 years old, they will need help to brush their teeth. Try brushing their teeth first and then letting them finish. Teach parents that infants should not be put to bed with a bottle; this causes tooth decay and ear infections. Limit snacks to three to four per day. Avoid sugary snacks and drinks and sticky candy.
- [Ask students: what are some of the normal, age-related changes to the oral cavity that occur in older adults? Discuss. Thinning of the oral mucosa and decreased vascularity of the gingivae predispose older adults to injury and periodontal disease. Loss of tissue elasticity and decreased mass and strength of the muscles make chewing more difficult. Loss of the alveolar bone can loosen natural teeth. The number of taste buds declines with advancing age. Plaque retention is a problem in older adults and is worsened by existing tooth restorations, missing teeth, gingival recession, and wearing of a removable prosthesis. Some older adults may experience difficulty maintaining good oral hygiene with flossing and brushing because of decreased dexterity and failing eyesight. It is recommended that an adult not smoke, chew tobacco, or use snuff. Smoking may impair blood flow to the gums, reducing the amount of oxygen and nutrients to the tissues and make them more vulnerable to infection.
- Oral bacteria from multiple strains and Candida species are found on acrylic dentures. Routine denture care reduces the risk for gingival infection. Dentures can easily be lost or broken. Handle them with care.
- [Discuss the consequences of various water temperatures when caring for dentures.]
- Correct answer: A Rationale: Ill-fitting dentures can impair eating. If dentures do not fit properly, the patient may experience pain and/or difficulty eating.
- Unconscious or debilitated patients pose challenges because of their risk for alterations of the oral cavity from drying of the mucous membrane, thickened secretions, and an inability to eat or drink. Debilitated patients are also at risk for aspiration. They are susceptible to infection because of the change in the normal flora of the oral cavity and are at risk for infection because of increased plaque formation from dryness of the mouth and decreased salivation. Although saliva production is decreased, saliva is present and can pool in the back of the oral cavity; this is another contributing factor placing the patient at risk for aspiration. Secretions in the oral cavity change very rapidly to gram-negative pneumonia-producing bacteria if aspiration occurs. The critically ill patient faces risk factors for oral problems such as dehydration, dryness of the oral mucosa, chemical injury to the mucosa, and oral trauma. Once intubated, an endotracheal tube causes a bypass of normal defenses, which also causes a rapid change in the normal oral flora. Some patients require mouth care as often as every 1 to 2 hours until the mucosa returns to normal. Many patients have no gag reflex as a result of a change in consciousness or a neurological injury. While providing oral care to an unconscious patient, protect him or her from choking and aspiration. Proper oral hygiene requires keeping the oral mucosa moist and removing secretions that lead to infection. Chlorhexidine. 12% gel or mouth rinse every 12 hours has been shown to effectively prevent VAP. Check agency policy regarding the use of CHG in oral care.
- The nurse must first assess the patient for a gag reflex. The nurse instructs the NAP to: Have another NAP assist and properly position patient for mouth care. Be aware of special precautions such as aspiration precautions. Use an oral suction catheter for clearing oral secretions (see Skill 25-1). Report signs of impaired integrity of oral mucosa to the nurse. Report any bleeding of mucosa or gums, excessive coughing, or choking to the nurse. I was not able to verify this cross reference. Please verify if possible.
- [Ask students: what are some examples of pertinent observations? Discuss: presence of gag reflex, presence of bleeding gums, dry mucosa, ulcerations, and crusts on tongue.]
- Teaching Family members may care for debilitated patient in the home. Instruction on how to perform mouth care is necessary so family understands how to protect patient from aspirating while thoroughly cleaning oral cavity. Utilize the teach-back technique by observing family caregiver perform mouth care procedure effectively or asking them to describe the procedure. Home care Irrigate oral cavity with bulb syringe; if unavailable, substitute gravy baster or large syringe. Caution family caregiver against instilling a large amount of water or rinsing agent in the oral cavity because of the risk of aspiration. Observe caregiver use baster. Encourage family caregiver to clean patient’s mouth at least twice a day. If patient breathes through mouth, a soft-bristled toothbrush moistened and used every 1 to 2 hours will keep mouth moist and fresh.
- Appearance and sense of well-being are influenced by how the hair looks and feels. Most long-term care facilities have beauty shops where patients can go for professional hair care. Diaphoresis leaves hair oily and unmanageable. Proper hair care is important to a person’s body image. [Ask students: what are some of the factors that can influence the condition of the patient’s hair: fever, malnutrition, emotional stress and depression, diaphoresis, hormone changes, aging, excessive use of shampoo, chemotherapy agents, radiation therapy.] Certain chemotherapy agents and radiation therapy cause loss of hair (alopecia). Many patients choose to wear a wig; however, some choose to wear hair scarves or turbans. [Review with students Table 18-2, Hair and Scalp Problems.] Shaving facial hair is a task that most men prefer to do for themselves daily. Because some religions and cultures forbid cutting or shaving any body hair, be certain to obtain consent from these patients.
- [Ask students: what kinds of concerns might need to be reported? Discuss: neck pain, bleeding, problem skin areas.]
- In some health care agencies, you need a health care provider’s order to shampoo a patient who is dependent or has limited mobility because it is challenging to find ways to shampoo the hair without causing injury. More frequent shampooing is necessary when patients remain in bed for extended periods, have excessive perspiration, or undergo treatments that leave blood or solutions in the hair. Caution is needed with patients who have suffered neck injuries because flexion and hyperextension of the neck could cause further injury. In addition, patients with positional vertigo are not able to tolerate neck hyperextension if it increases their dizziness. A folded towel placed under the neck on the edge of the sink provides added comfort. If a patient is allowed to sit, you can shampoo her hair in a chair in front of a sink. If the patient cannot sit in a chair or be transferred to a stretcher, you will need to shampoo her hair while she is in bed.
- [Discuss various positions for patients with mobility restrictions of the head or neck.]
- [Discuss with students Table 18-3, Common Foot and Nail Problems.] The best time for nail and foot care is during the bath. Many agencies require a health care provider’s order before you can trim nails. Peripheral neuropathy and peripheral vascular disease cause a reduction in blood flow to the extremities and loss of sensory, motor, and autonomic nerve function. As a result, a patient is unable to feel heat and cold, pain, pressure, and positioning of the foot or feet. The reduction in blood flow impairs healing and increases risk for infection. The development of diabetic foot ulcers has three contributing factors: 1. Peripheral neuropathy (changes in the function and efficiency of the nerves). 2. Ischemia (decreased blood flow related to plaque formation in the arteries). 3. A pivotal event (trauma caused by banging the toe or stepping on a foreign object). If foot ulcers do not heal, they can quickly become infected, leading to gangrene and subsequent amputation.
- [Discuss why it is important to report any redness or other changes in the skin.]
- [Remind students how a delay in reporting ulcerations or other skin problems can have a negative outcome.]
- Teaching Use a variety of teaching formats regarding foot and nail care (e.g., brochures, videos, DVDs) that are consistent with patient’s health literacy level. Instruct a patient with diabetes, peripheral neuropathy, or peripheral vascular disease to do the following: Check your feet every day. Look at your bare feet for red spots, cuts, swelling, and blisters. If you cannot see the bottoms of your feet, use a mirror or ask someone for help. Be more active. Plan a physical activity program with your health care team. Ask your doctor about Medicare coverage for special shoes. Wash your feet every day. Dry them carefully, especially between the toes. Keep your skin soft and smooth. Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between your toes. If you can see and reach your toenails, trim them when needed. Wear shoes and socks at all times. Never walk barefoot. Wear comfortable shoes that fit well and protect your feet. Check inside your shoes before wearing them. Make sure the lining is smooth and there are no objects inside. Protect your feet from hot and cold. Wear shoes at the beach or on hot pavement. Don't put your feet into hot water. Test water before putting your feet in it just as you would before bathing a baby. Never use hot water bottles, heating pads, or electric blankets. You can burn your feet without realizing it. Put your feet up when sitting. Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day. Don't cross your legs for long periods of time. Don't smoke.
- Gerontological Changes in aging skin include thinning of epidermis and subcutaneous fat and dryness caused by decreased activity of oil and sweat glands. These changes are often evident in the feet. In addition, nails become discolored, thickened, deformed, and brittle. Peripheral vascular disease (PVD), peripheral neuropathy, and long periods of limited exercise or bed rest influence balance, stability, and sensory impairment, resulting in impaired mobility. Older adults may lose the dexterity and coordination needed to trim nails regularly. Home care [Ask students: what kinds of things could cause a foot injury in a patient’s home? Discuss: rugs, objects that block pathways, or uneven walks or flooring.] Assess the home for any areas where a person could accidentally injure the feet such as rugs, objects that block pathways, or uneven walks or flooring. Encourage patients to not go barefoot or wear open-toed shoes. Alternative therapy: apply moleskin to friction areas of the foot or feet, or wrap small pieces of lambswool around toes to reduce irritation from corns or bunions. Include family caregiver in foot and nail care education. Place contact information of podiatrist, health care provider, and home care nurse close by for easy access.
- The hospital bed is the piece of equipment a patient uses the most. The frame is divided into three sections so the operator can raise and lower the head and foot of the bed separately and incline the entire bed with the head up or down. Beds have side rails (adjustable metal frames) that you can raise or lower by pushing or pulling a knob located on both sides of a bed. Research shows that the risk for patient falls is greater when side rails on both sides of a bed are raised because patients try to climb over the rails to exit the bed. [Review Table 18-4 with students: Common Bed Positions] If a patient is confined to bed, you should make the bed in a way that conserves time and the patient’s energy. In cases in which a patient experiences severe pain, an analgesic administered 30 to 60 minutes before a procedure helps to control pain and maintain comfort. Even though a patient is unable to get out of bed, encourage self-help as much as possible. For example, the patient can turn, help while moving up in bed, or hold top sheets while you apply linen. These activities help maintain the patient’s strength and mobility and allow participation in hygiene care.
- Observe good body mechanics, and support alignment of patient if needed. Aspiration precautions include: Keeping head of bed (HOB) raised to no lower than 30 degrees. Explaining need to report excessive coughing or choking during procedure.
- Moisture on bed linen can easily lead to skin breakdown. An unoccupied bed is one left open with the top sheets fanfolded down. A postoperative surgical bed is prepared for patients returning from the operating room (OR) or procedural area. The bed is left with the top sheets fanfolded lengthwise and not tucked in, to facilitate a patient’s transfer from a stretcher. A closed bed, which is made with the top sheets pulled up to the head of the bed, is used after a patient is discharged and housekeeping cleans the unit.